Why? How? What next?

Why?Why?

How?How?

What next?What next?

World Health Organization

1 year 2 years 3 years 4 years 5 years

WHO Child Growth StandardsWHO Child Growth Standards

Why?Why?



NCHS/WHO international reference NCHS/WHO international reference and national referencesand national references

National Center for Health Statistics (NCHS) and WHO National Center for Health Statistics (NCHS) and WHO referencereference

recommended in 1977recommended in 1977 developed based on longitudinal data (0-3 yrs) and on 3 cross-developed based on longitudinal data (0-3 yrs) and on 3 cross-

sectional studies (older children) of American populationsectional studies (older children) of American population The infant population predominantly artificially fedThe infant population predominantly artificially fed

National growth references National growth references Mostly also non-breastfed or mixed fed children (well Mostly also non-breastfed or mixed fed children (well

documented in e.g. Czech republic)documented in e.g. Czech republic)

Source: de Onis et al. Worldwide practices in child growth monitoring. Journal of Pediatrics 2004;144:461-5.

Worldwide practices in child growth monitoring

Reference population

Reference

CountriesNumber %

NCHS/WHO 99 68Tanner 3 2Harvard 13 9Local 25 17Other 17 12Unknown 6 4

Milestones in the development of new Milestones in the development of new international growth referenceinternational growth reference

1991-19931991-1993 WHO Working Group on Infant GrowthWHO Working Group on Infant Growth

Comprehensive review shows growth patterns of healthy breastfed infants differ from the current Comprehensive review shows growth patterns of healthy breastfed infants differ from the current NCHS/WHO international reference NCHS/WHO international reference

A new growth reference is needed to improve infant health managementA new growth reference is needed to improve infant health management

The reference population should reflect health recommendations in view of the frequent use of The reference population should reflect health recommendations in view of the frequent use of references as “standards”references as “standards”

WHO Multicentre Growth Reference Study

Mean z-scores of healthy breastfed infants Mean z-scores of healthy breastfed infants relative to the NCHS/WHO referencerelative to the NCHS/WHO reference

Source: An Evaluation of Infant Growth, WHO, 1994

Source: An Evaluation of Infant Growth, WHO, 1994

Rationale for the development of new Rationale for the development of new international growth referenceinternational growth reference

The current NCHS/WHO international referenceThe current NCHS/WHO international reference is inappropriate for assessing nutritional status:is inappropriate for assessing nutritional status:

Individual infantsIndividual infants interferes with sound nutritional management of breastfed interferes with sound nutritional management of breastfed

infants thus increasing risk of morbidity and mortalityinfants thus increasing risk of morbidity and mortality

PopulationsPopulations provides inaccurate community estimates of under- provides inaccurate community estimates of under- and overnutritionand overnutrition


Standard vs. referenceStandard vs. reference

StandardStandardPrescriptive –Prescriptive –

Showing how children Showing how children

SHOULD growSHOULD grow

Reference Reference Descriptive – Descriptive –

Showing how a sample Showing how a sample of a given population of a given population grow (regardless of its grow (regardless of its nutritional and other nutritional and other conditions)conditions)

Rationale for the development of new international growth reference

Upward bias

of reference population

childhood obesity

How?How?



A Growth Curve for the A Growth Curve for the 21st Century21st Century

Nutrition for Health and DevelopmentWorld Health Organization

Geneva, Switzerland

The WHO Multicentre The WHO Multicentre Growth Reference Growth Reference

StudyStudy

Optimal NutritionOptimal Nutrition– Breastfed infantsBreastfed infants– Appropriate complementary feedingAppropriate complementary feeding

Optimal EnvironmentOptimal Environment– No microbiological contaminationNo microbiological contamination– No smokingNo smoking

Optimal Health CareOptimal Health Care– ImmunizationImmunization– Pediatric routinesPediatric routines

OptimalGrowth

Growth Reference StudyGrowth Reference StudyPrescriptive ApproachPrescriptive Approach


Eligibility criteria of study populationEligibility criteria of study population

SES that does not constrain growthSES that does not constrain growth Altitude < 1,500mAltitude < 1,500m Low mobility target populationLow mobility target population Minimum 20% of mothers follow feeding Minimum 20% of mothers follow feeding

recommendationsrecommendations Existing breastfeeding support systemExisting breastfeeding support system Presence of collaborative institutionsPresence of collaborative institutions


Eligibility criteria of individualsEligibility criteria of individuals

No health, environmental or economic constraints on No health, environmental or economic constraints on growthgrowth

Mother willing to follow feeding recommendationsMother willing to follow feeding recommendations Term birthTerm birth Single birthSingle birth Lack of significant perinatal morbidityLack of significant perinatal morbidity No smoking mothers (before and after delivery)No smoking mothers (before and after delivery)


MGRS study designMGRS study design

year 1year 1 year 2year 2 year 3year 3

Longitudinal (0-24 months)Longitudinal (0-24 months)

Cross-sectional (18-71 mo)Cross-sectional (18-71 mo)


Time schedule child anthropometryTime schedule child anthropometry

Measurement Time frame Frequency No. of visits

Birth Once 1

Weeks 2-8 Bi-weekly 4

3-12 months Monthly 10

Weight, length, head circumference

14-24 months Bi-monthly 6

3-12 months Monthly 10 Arm circumference Skinfold thicknesses 14-24 months Bi-monthly 6


Motor developmentMotor development

Six universal motor Six universal motor

development development

milestones assessed milestones assessed

between 4 and between 4 and 18 18

months of age months of age



Motor Development Assessment

Sample sizeSample size

Total sample > 8,400 by combining:

– cohorts 300 newborns per site

– 1,400 children aged 18 to 71 months per site

Target of growth curves: 400 both sexes


Measurement and Measurement and standardization protocolsstandardization protocols

Rigorous scientific standards are Rigorous scientific standards are

applied to a complex cross-cultural applied to a complex cross-cultural

field-based project. field-based project.



The WHO Multicentre Growth Reference Study The WHO Multicentre Growth Reference Study

Rationale, Planning & ImplementationRationale, Planning & Implementation

Food and Nutrition Bulletin

vol 25, no.1 (supplement)

March 2004

What What next?next?

WHO Child Growth Standards


1990 91 92 93 94 1995 96 97 98 99 2000 01 02 03 04 2005 06 07 08 09 2010

WHA Resolution

(May 1994)

WHO Working Group on Infant Growth

WHO Working Group on Growth Reference

Protocol


Field implementation

(July 97)

(Nov 03)

Growth Standards

2nd set

Construction and testing of growth

standards

Growth Standards 1st set: Weight-for-age, length/height-for-age, weight-for-length/ height, BMI-for-age and motor development indicators.

Growth Standards 2nd set: Arm-Circumference-for-age, Triceps skinfold-for-age,

Subscapular skinfold-for-age and Head circumference-for-age.

WHO Expert Committee recommendation

(Nov 1993)

Growth Standards

1st set

WHO Child Growth Standards TimelineWHO Child Growth Standards Timeline

WHO - MGRS / reference indicatorsWHO - MGRS / reference indicators Attained growth

weight-for-age length/height-for-age weight-for-length/height head circumference-for-age mid-upper arm circumference-for-age triceps skinfold-for-age subscapular skinfold-for-age body mass index-for-age

Velocity weight length head circumference• arm circumference• body mass index



Innovative aspectsInnovative aspects

Prescriptive approach recognizing need for standards

Breastfed infant as normative model

International sample

Reference data for assessing childhood obesity

Velocity reference data

Link between physical growth and motor development

WHO Child Growth StandardsWHO Child Growth Standards2004-20102004-2010

Construction of standards Evaluation and field testing of provisional standards Develop WHO/MGRS software to support individual- and

population-based uses Develop training modules to guide appropriate use Review interventions to prevent/treat impaired child growth Develop roll-out strategy with partners, oversee global and

country level implementation of the new standards Adapt global monitoring system for MDG tracking

WHO Department of Nutrition for Health and Development

Strategy for promoting healthy growth Strategy for promoting healthy growth and developmentand development

Training on itsTraining on its

appropriateappropriate

use and use and

interpretationinterpretation


Development Development

of a soundof a sound

international international

growth growth

referencereference

Clinical andClinical and

Public HealthPublic Health

InterventionsInterventions

Child survivalChild survival

Physical growthPhysical growth

Child developmentChild development


Documents

Why? How? What next?